(NGN) HESI RN EXIT EXAM FROM REAL EXAM
SCREENSHOTS V1-V7 LATEST VERSIONS 2024
ALL QUESTIONS ANSWERED WITH
RATIONALES
Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of
70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour
for the last two hours. What pathophysiological reason supports the nurse's decision to report this
finding to the healthcare provider
a. This output is not sufficient to cleat nitrogenous waste
b.
c. Low urine output puts the client at risk for fluid overload
d. An increased urine output is expected after splenectomy
Oliguria signals tubular necrosis related to hypoperfusion
Rationale: Prolonged low blood pressure leads to renal ischemia, which is the common etiology of
acute tubular necrosis(ATN) Decreasing urine output is an early indicator of ATN.
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on
what data ensures quality client care and is most cost-effective?
a. Client geographic location and age
b. Number of staff and number of clients
c. Weekend and weekday staff availability
d.
Skills of staff and client acuity
,When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD),
which approach should the nurse use?
a. Perform the drainage immediately after meals
b. Instruct the client to breath shallow and fast
c. Obtain arterial blood gases (ABG's) prior to procedure
d.
Explain that the client may be placed in five positions
Rationale: Frequently, the client is placed in five positions (head down, prone, right and left lateral,
and sitting upright) to aid in drainage of each of the five lobes of the lungs (D). Postural drainage
should be performed before meals to prevent nausea, vomiting and aspiration(A). The client should
breath slow and exhale through pursed lips to help keep airway open so that secretions can be drained
while assuming the various positions. C is not required
A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client
to perform a series of movements that require use of the facial muscles. What symptoms suggest that
the client has most likely experience a Bell's palsy rather than a stroke?
a. Slow onset of facial drooping associated with headache
b.
c. A flat nasolabial fold on the right resulting in facial asymmetry.
d. Drooling is present on right side of the mouth, but not on the left.
Inability to close the affected eye, raise brow, or smile
Rationale: Because the motor function controlling eye closure, brow movement and smiling are all
carried on the 7th cranial (facial) nerve, the combination of symptoms directly relating to an
impairment of all branches of the facial nerve indicate that Bell's palsy has occurred.
The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return
demonstration, which action indicated that the client understood the teaching?
,a. Turns to left the side to instill the irrigating solution into the stoma
b.
c. Instills 1,200 ml of irrigating solution to stimulate bowel evacuation
d. Inserts irrigating catheter deeper into stoma when cramping occurs
Keeps the irrigating container less than 18 inches above the stoma
Rationale: Keeping the irrigating container less than 18 inches above the stoma permits the solution to
flow slowly with little excessive peristalsis does not cause immediate release of stool.
The nurse should teach the client to observe which precaution while taking dronedarone?
a. Stay out of direct sunlight
b.
c. Reduce the use of herbal supplements
d. Minimize sodium intake.
b. Avoid grapefruits and its juice
Rationale: Dronedarone is a Class III antiarrhythmic drug that works to restore the normal sinus
rhythm in patients with paroxysmal or persistent atrial fibrillation. Grapefruit increase the effect of
dronedarone thereby increasing the possibility of serious side effects. A does not cause a serious effect.
C may potentiate lethal arrhythmias and should be avoided. D does not directly affect those taking
dronedarone.
A client who sustained a head injury following an automobile collision is admitted to the hospital. The
nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care.
Which signs indicate to the nurse that ICP has increased?
a. Increased Glasgow coma scale score.
b. Nuchal rigidity and papilledema.
c.
d. Periorbital ecchymosis.
, Confusion and papilledema
Rationale: Papilledema is a condition in which increased pressure in or around the brain (intracranial
pressure) causes swelling of the part of the optic nerve inside the eye (optic disc). Papilledema is always
an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do
not necessarily reflect increased ICP.
The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous
catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the
risk for infection?
a. Remind staff to follow protective environment precautions
b. Gently flush the catheter lumen with sterile saline solution
c. Cleanse the site and change the transparent dressing.
d.
Confirm the necessity for continued use of the CVC
Rationale: Increase the length of use increase the risk for infection. The CVC care bundle includes the
review of the need for continued use of the CVC. Effective hand hygiene and standard precautions
should be maintained but protective environment precautions are not needed. B is not needed if
continuous IV fluid are infused, ad may introduce contaminants. Use of a transparent dressing allows the
site to be visualized for any signs of infection but changing the dressing daily increases the risk for
infection.
During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to
be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks
later is most indicative that the client has diabetes mellitus (DM)?
a. An increased thirst with frequent urination
b. Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI)
c. Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9 mmol/L (SI)
d.
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